Your Name *

First Name

Last Name

Your Phone *

(###)

###

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Your Date of Birth

MM

DD

YYYY

During virtual sessions, I will: *

use insurance benefits and will be located in Kansas or Missouri.

not use insurance benefits and will be located in one of the states listed above.

Is your concern within Dr. Barreca’s scope of practice? *

I want to work on co-occurring medical and mental health challenges or on specific goals.

I can attend appointments on Thursdays or Fridays.

I am NOT seeking specialty treatment (e.g., substance dependence, personality disorder, trauma, dementia, eating disorders, psychosis, chronic suicidality, and OCD).

I understand that Dr. Barreca does not provide disability assessments.

I understand that virtual CBT is not suitable for crises or intensive mental health or substance treatment. Please call 911, 988, or go to the ER in a crisis or emergency.